RESEARCH THE SURGICAL MANAGEMENT AND SPEECH AND SWALLOWING REHABILITATION

RESEARCH
THE SURGICAL MANAGEMENT AND SPEECH AND SWALLOWING REHABILITATION
OF PATIENTS WITH ADVANCED TONGUE CANCER IN SOUTH AFRICA
Leanie Engelbrecht
M Communication Pathology
Masters student, Department of Communication Pathology, University of Pretoria
Anita Van der Merwe
D Phil (Speech Pathology)
Professor, Department of Communication Pathology, University of Pretoria
Corresponding author: [email protected]
Jan P Pretorius
M Med (Surgery)
Professor, Department of Surgery, Faculty of Health Sciences, University of Pretoria
Keywords: surgical management; speech and swallowing rehabilitation; advanced tongue cancer
ABSTRACT
Advanced tongue cancer may have a devastating effect on a person’s ability to speak and to swallow. Very little is
known about the surgical management and speech and swallowing rehabilitation of persons with advanced tongue
cancer in South Africa. The aim of this study was to obtain information regarding clinical practices in treatment and
rehabilitation. Questionnaires were distributed to 450 surgeons and 150 speech-language pathologists in South
Africa. The response rate was 16% for the surgeons and 33% for the speech-language pathologists. Results
showed that only a small number of surgeons and speech-language pathologists in South Africa are involved in the
treatment of persons with advanced tongue cancer. Surgeons prefer combined modality treatment (surgery and
post-operative radiotherapy) in the primary treatment of patients with advanced tongue cancer, but the use of radiochemotherapy is growing. Total glossectomy is a very radical procedure, but it is sometimes used by surgeons to
treat patients with advanced disease. Total glossectomy with laryngeal preservation is preferred to total glossolaryngectomy by surgeons, in order to preserve laryngeal voice. Patients with total glossectomy form only a small
part of the caseload of speech-language pathologists. Swallowing rehabilitation includes aspects such as dietary
changes, compensatory swallowing techniques and airway protection mechanisms. Speech intelligibility is targeted
in speech rehabilitation, but alternative communication is sometimes recommended for patients who have undergone total glosso-laryngectomy.
OPSOMMING
Gevorderde tongkanker het ‘n geweldige impak op ‘n persoon se vermoë om te praat en te sluk. Baie min inligting
is bekend oor die chirurgiese behandeling en spraak- en slukrehabilitasie van persone met gevorderde tongkanker
in Suid-Afrika. Die doel van hierdie studie was om inligting te verkry aangaande die kliniese praktyk in behandeling
en rehabilitasie. Vraelyste is aan 450 chirurge en 150 spraak-taalterapeute in Suid-Afrika gestuur. Die responssyfer
was 16% vir die chirurge en 33% vir die spraak-taalterapeute. Resultate toon dat slegs ‘n klein aantal chirurge en
spraak-taalterapeute in Suid-Afrika betrokke is by die behandeling van pasiënte met gevorderde tongkanker.
Chirurge verkies kombinasie behandeling (chirurgie met post-operatiewe radioterapie) in die primêre behandeling
van pasiënte met gevorderde tongkanker, maar die gebruik van chemo-radioterapie is besig om toe te neem. Totale
glossektomie is ‘n radikale prosedure, maar word soms deur chirurge uitgevoer om pasiënte met gevorderde siekte
te behandel. Totale glossektomie word verkies bo totale glosso-laringektomie deur chirurge ten einde laringeale
stem te behou. Totale glossektomie-pasiënte vorm ‘n klein gedeelte van spraak-taalterapeute se gevalslading.
14
HEALTH SA GESONDHEID Vol.11 No.3 - 2006
Slukrehabilitasie sluit aspekte soos dieetaanpassing, kompensatoriese sluktegnieke en lugwegbeskermingstegnieke
in. Spraakverstaanbaarheid word geteiken in spraakrehabilitasie, maar alternatiewe kommunikasie word soms
aanbeveel vir pasiënte wat totale glosso-laringektomie ondergaan het.
INTRODUCTION AND BACKGROUND
The rehabilitation of patients with head and neck cancer
has evolved into “a very complex speciality, demanding
expertise in various disciplines” (Shah, 1996:iv). In South
Africa many patients present with advanced head and
neck cancer as a result of the large number of patients
coming from rural areas. A great number of these
patients need radical treatment because of the advanced
stage of the cancer at the time of presentation. Very
little is known about the surgical procedures and
practices of South African head and neck surgeons
regarding the treatment of advanced tongue cancer
patients. Surgeons may choose from a variety of
treatment options, or refer the patient for radiotherapy
and/or chemotherapy. The nature of the medical
treatment (for example surgery, radiotherapy or
chemotherapy) will impact on the rehabilitation needs
of the patient, including speech and swallowing
rehabilitation. Little is known about speech-language
pathologists’ experience of treating patients with
advanced tongue cancer and their knowledge of the
effects of surgical treatment on communication and
swallowing. Currently, there is no standard approach
followed in medical institutions in South Africa regarding
the surgical management and rehabilitation of patients
with advanced tongue cancer. It is therefore essential
to establish a database of information regarding the
surgical management and speech and swallowing
rehabilitation of patients with advanced tongue cancer
in South Africa. For the speech-language pathologist
to effectively treat speech and swallowing problems of
patients with advanced tongue cancer, it is important
to be acquainted with the current practices regarding
the surgical management of these patients. However,
patients who undergo treatment for tongue cancer have
many diverse needs and a multidisciplinary team
consisting of a professional nurse, physiotherapist,
psychologist, social worker, surgeon, radiotherapist and
oncologist thus has a crucial role to play in the
management of patients with head and neck cancer.
Oncological and surgical management of
advanced tongue cancer
HEALTH SA GESONDHEID Vol.11 No.3 - 2006
The treatment of advanced tongue cancer is a controversial issue in head and neck oncology with
important implications for the patient in terms of posttreatment functioning and quality of life (Mendenhall,
Stringer, Amdur, Hinerman, Moore-Higgs & Cassisi,
2000:35; Harrison, Ferlito, Shaka, Bradley, Genden &
Rinaldo, 2003:101). Several treatment options are
available, including surgery, radiotherapy and chemotherapy, or a combination of these procedures.
Combined modality treatment (for example, surgery and
post-operative radiotherapy or chemo-radiation) is
required for patients with advanced disease. Surgical
resection, followed by immediate reconstruction, neck
dissection (unilateral/bilateral) and post-operative
radiation therapy is considered the favoured combination
of treatment modalities for patients with advanced
tongue disease (Salibian, Allison, Rappaport, Krugman,
McMicken & Etchepare, 1989:513; Sultan & Coleman,
1989:298; Shah, 1996:175; Mactay, Perch, Markiewicz,
Thaler, Challian, Goldberg, Kligerman & Weinstein,
1997:495; Ruhl, Gleich & Gluckman, 1997:1316;
Robertson, Gleich, Barrett & Gluckman, 2001:1364).
However, the role of combined chemo-radiotherapy in
the treatment of advanced tongue cancer is growing
(Harrison et al. 2003:101).
When surgery is performed, total glossectomy is often
required in cases of advanced tumours (referred to as
T3 or T4 depending on the size of the tumour) that affect
the whole tongue or the base of the tongue (Shah,
1996:179; Götert & Aras, 1999:75). The efficacy of total
glossectomy for advanced carcinoma of the tongue
remains controversial (Sultan & Coleman, 1989:297).
This procedure necessarily impacts permanently upon
both speech and swallowing (Davidson, Brown &
Gullane, 1993:163). When the tumour involves the
valleculae or pre-epiglottic space, total laryngectomy
also needs to be performed to obtain clear surgical
margins. This operation is known as a total glossolaryngectomy. An important reason for performing total
glosso-laryngectomy is to prevent the aspiration of food
that may follow after total glossectomy. The main
implication of total glosso-laryngectomy is that laryngeal
voice is lost. However, the advantage is that aspiration
15
is eliminated. Total glosso-laryngectomy is extremely
radical surgery. Harrison states that total glossolaryngectomy should be “viewed as a last resort, as
the functional and psychological consequences are
profound” (Harrison et al. 2003:102).
Communication and swallowing problems following total glossectomy and total
glosso-laryngectomy
The general perception is that intelligible speech without
a tongue is not possible. To the contrary, numerous
studies indicate that fairly intelligible speech is possible
after total glossectomy (Morrish, 1984:125; Morrish,
1988:13; Davidson et al. 1993:160; Knuuttila, Pukander,
Määttä, Pakarinen & Vilkman, 1999:621; Fox & Rau,
2001:161; Furia, Kowalski, Latorre, Angelis, Martins,
Barros & Ribeiro, 2001:378). According to Knuuttila et
al. (1999:622) speech can be astonishingly intelligible
after a total glossectomy, even though the tongue is of
central importance for the production of consonants and
vowels. Speech intelligibility can be enhanced by
teaching the patient compensatory speech techniques,
such as overemphasis of suprasegmental aspects of
speech (reduced speech rate, stress and intonation).
Speech intelligibility is also enhanced by the fact that
listeners “fill in” information not clearly articulated by
the speaker. Perception of speech is thus facilitated
by the large amount of redundancy in normal speech
(Morrish, 1988:13).
Preservation of the larynx is obviously of great help in
developing good post-glossectomy speech (Harrison,
1983:633). If a total glosso-laryngectomy is performed,
laryngeal voice is lost. All authors agree that when the
larynx is sacrificed, so is the potential for acceptable
speech rehabilitation. Weber, Ohlms, Bowman, Jacob
and Goepfert (1991:513) and Davidson et al. (1993:162)
state that when the larynx is sacrificed, acceptable
speech rehabilitation is not possible. Total glossolaryngectomy causes sudden and complete loss of
speech (Fox & Rau, 2001:161). Tracheo-oesophageal
speech offers a possible solution to these patients and
alternative communication aids can also be
implemented. However, if the patient is illiterate,
alternative communication may not be an option or may
be restricted to picture-based communication.
Total glossectomy will not only compromise speech,
16
but also the patient’s ability to chew and swallow food.
Swallowing problems, also referred to as dysphagia,
may occur. The major cause of dysphagia after total
glossectomy is a lack of force to transport the bolus
from the oral cavity to the pharynx, and from the pharynx to the oesophagus (Furia, Carrara de-Angelis,
Martins, Barros, Carneiro & Kowalski, 2000:382). Patients who have undergone total glossectomy are usually dependent on a liquid or puree diet because of the
lack of oral propulsive force. Procedures such as laryngeal suspension and cricopharyngeal myotomy that
facilitate bolus transportation from the oral cavity to the
oesophagus, may be useful in improving swallowing
after total glossectomy (Hirano, Kuroiwa, Tanaka,
Matsuoka, Sato & Yoshida, 1992:140).
General swallowing characteristics noted on
videofluoroscopy after total glossectomy with preservation of the larynx are an increase in oral transit time
and stasis of food in the oral cavity, pharynx and above
the superior oesophageal sphincter (Ruhl, Gleich &
Gluckman, 1997:1317; Furia et al. 2000:379). Patients
who have undergone total glossectomy use compensatory swallowing techniques and swallowing
manoeuvres to improve swallowing. Compensatory techniques include head tilting to direct food posteriorly,
increased buccal, mandibular, pharyngeal and laryngeal activity and voluntary protection of the larynx during swallowing. Movements comprising lip protrusion,
suction, and intra-oral space reduction through mandible movements also facilitate swallowing.
The need for a survey of the surgical management and speech and swallowing rehabilitation of patients with advanced
tongue cancer in South Africa
South Africa poses novel challenges to medical practitioners and rehabilitation team members. Patients coming from both first and second world settings have to be
managed according to their needs. The treatment of
advanced tongue cancer is in most instances radical
and will have profound implications for the life-style of
patients. Professionals have to be trained to serve this
diverse population with their specific needs. At present
very limited data on the surgical management and
speech and swallowing rehabilitation practices are available. The present study is a preliminary attempt to
determine the nature of current practices in South Af-
HEALTH SA GESONDHEID Vol.11 No.3 - 2006
rica regarding surgical procedures and speech and
swallowing rehabilitation, and also to determine how
many surgeons and speech-language pathologists are
involved in the treatment of advanced tongue cancer.
speech-language pathologists, 13 were involved in the
treatment of patients who have undergone total
glossectomy.
Material
RESEARCH
Aim of the study
The aim of this study was to determine current practices in South Africa regarding the surgical management, and speech and swallowing rehabilitation of patients with advanced tongue cancer.
Research design
An explorative survey design was followed (Neuman,
1997:20). The data collection tool was a mailed and
self-administered questionnaire. Questionnaires were
distributed to surgeons and speech-language
pathologists in South Africa.
Participants
Participants comprised two subgroups, namely surgeons (including general surgeons, ear, nose and throat
surgeons, and maxillo-facial and reconstructive surgeons) and speech-language pathologists. Questionnaires were sent to each of the 220 practising ear, nose
and throat specialists and each of the 90 practising
maxillo-facial surgeons in South Africa. Questionnaires
were also sent to a total of 140 general surgeons and
plastic and reconstructive surgeons. Simple random
sampling was used to select these 140 surgeons.
Speech-language pathologists in private practice and
at academic hospitals were included in the study. A
total of 50 questionnaires were sent to speech-language
therapists working in academic hospitals. All the academic hospitals in South Africa were included. Questionnaires were sent to 100 therapists in private practice. Simple random sampling was used to select the
speech-language pathologists in private practice.
Questionnaires were thus distributed to a total of 450
surgeons and 150 speech-language pathologists.
Seventy-three surgeons (16%) and 55 speech-language
pathologists (33%) returned their questionnaires. Of the
73 surgeons, only sixteen were involved in the treatment
of patients with advanced tongue cancer. Of the 55
HEALTH SA GESONDHEID Vol.11 No.3 - 2006
Two questionnaires were compiled. The one questionnaire was developed to determine case load and current
practices in surgical management of advanced tongue
cancer by surgeons and the other questionnaire was
aimed at determining case load and current practices
in speech and swallowing rehabilitation by speechlanguage pathologists.
The surgeons’ questionnaire contained questions
regarding caseload, modalities of treatment (surgery,
radiotherapy and chemotherapy), the utilisation of total
glossectomy versus total glosso-laryngectomy in the
primary treatment of patients with advanced tongue
cancer, referral practices and survival rates after total
glossectomy.
The speech-language pathologists’ questionnaire included questions regarding caseload, speech and swallowing rehabilitation of total glossectomy patients, referral practices and the need for more intensive undergraduate training. Speech rehabilitation may entail compensatory articulation training or the implementation of
augmentative and alternative communication methods.
Swallowing rehabilitation refers to the techniques introduced by the speech language pathologist to aid the
patient in overcoming the difficulties in swallowing created by total glossectomy. The range of methods aimed
at improving swallowing may consist of various compensatory swallowing techniques, feeding aids and diet
modifications. Questions on all of these aspects of rehabilitation were included in the questionnaire.
To enhance response rates, questionnaires were kept
relatively short. Questionnaires were accompanied by
information letters and a request for participation by
two widely known head and neck surgeons in South
Africa. Surgeons were reminded via electronic mail to
respond to the questionnaires. Speech-language
pathologists were phoned and reminded to respond to
the questionnaires.
17
Reliability and validity of the questionnaire
To ensure the reliability and validity (Neuman, 1997:140)
of the questionnaire, experts were consulted with regard to content and formulation of questions and then
a pilot study was conducted. Two surgeons (one general and one ear, nose and throat surgeon) and a
speech-language pathologist experienced in the field
of head and neck cancer were asked for input regarding the questions in the questionnaire. The preliminary
questionnaire was then completed by two other surgeons and two other speech-language pathologists. The
four pilot subjects were interviewed to discuss the aspects of the questionnaire that needed refinement.
Changes were then made to the questionnaire.
cer per year. The biggest annual caseload of patients
(50 patients by two participants respectively) with advanced tongue cancer were reported by surgeons working in both academic hospitals and in private practice,
as opposed to surgeons in private practice alone.
With regard to the utilisation of total glossectomy, six
of the 16 surgeons never perform total glossectomy or
any variation of it; four of the 16 surgeons only perform
total glossectomy with laryngeal preservation; one of
the 16 surgeons performs both total glossectomy with
laryngeal preservation or total glossectomy with partial
laryngectomy; two of the 16 surgeons only perform total glosso-laryngectomy (thus never preserving the larynx); and three of the 16 surgeons perform all the variations.
Data analysis
Five participants who perform total glosso-laryngectomy
Each participant received a number as the questionnaires were received. The data were processed thereafter by means of descriptive statistics. A frequency
table was compiled for each question. An absolute
frequency analysis was applied as the aim was to
determine the number of positive and negative responses
to each question or to determine the number of
individuals in different categories. The data were summarised in tables and figures, according to the
categories of the questionnaire.
RESULTS
Current practices in surgical management
Surgeons were asked to indicate the number of patients with advanced tongue cancer treated annually
and the surgical procedures that they perform on patients with advanced (T3 & T4) cancer of the tonguebase. They were asked to provide an estimated number and not an exact number, as it was foreseen that
this would foster a higher return rate from surgeons
who have been practising for a great number of years in
busy practices. As there are not that many patients
who undergo glossectomy, the estimated number should
be fairly accurate. The results are shown in Table 1.
The number of patients with T3 or T4 cancer of the
tongue or tongue-base treated by the 16 participants
ranged between one and fifty annually. Participants
treated an average of 10 patients with this type of can-
18
indicated that this is done to prevent chronic aspiration. Six participants who do not resect a healthy larynx justified this choice with the following reasons:
surgery is unnecessary if there is no cancer in the larynx (take an adequate margin but treat the larynx on
its merits); the loss of voice together with swallowing
problems is tragic in view of survival; the rehabilitation
of speech and swallowing after total glosso-laryngectomy in South-African black patients with disadvantaged
backgrounds is very difficult; a laryngectomy can always be done at a later stage; it depends on the mobility of the epiglottis.
There are alternative modalities of treatment available
for the treatment of T3 and T4 cancer of the tongue,
apart from surgery. Surgeons were asked to indicate
the modalities or combination of modalities used in the
treatment with these two different stages of tongue
cancer. The results are summarised in Tables 2 and 3.
Surgical resection (as single modality treatment) is
utilised by 10 of the 16 participants (four always and
six sometimes), while two participants never make use
of surgical resection. Radiotherapy (as single modality
treatment) is used by 12 participants (six always and
six sometimes); one participant never makes use of
radiotherapy. The combination of surgical resection and
post-operative radiotherapy is used by 14 participants
(seven always and seven sometimes). Brachytherapy
(as single modality treatment) is used by six participants (one always and five sometimes), while four par-
HEALTH SA GESONDHEID Vol.11 No.3 - 2006
HEALTH SA GESONDHEID Vol.11 No.3 - 2006
19
Table 1: Annual caseload of T3 and T4 tongue cancer patients for each surgeon and indications of the surgical practices used
ticipants never make use of brachytherapy. Chemotherapy (as single modality treatment) is used by 12
participants (six always and six sometimes).
The majority of the surgeons (14) use combined
modalities of treatment (surgery and post-operative radiotherapy). As single modalities of treatment, radiotherapy is used by 12 participants, chemotherapy also
by 12 participants, surgical resection by 10 participants
and brachytherapy by six participants. It appears that
each patient is considered individually by the surgeon
in terms of which option or options of treatment to recommend for the specific patient, as at least 12 participants make use of all the available modalities. Although
the majority of surgeons prefer combined surgery and
radiotherapy for treatment, literature (and the current
data) shows that the use of chemo-radiotherapy (organ
preservation protocols) is growing in favour of radical
surgery in the treatment of advanced head and neck
cancer (Harrison, Lee, Pfister, Kraus, White, Raben,
Zelefsky, Strong & Shah, 1998:668; Harrison et al.
2003:101).
Table 2: Modalities of treatment used in the management of patients with T3 cancer of the tongue or base
of the tongue as indicated by participants
TREATMENT MODALITY
NUMBER OF PARTICIPANTS
TOTAL NUMBER
OF PARTICIPANTS
ALWAYS
SOMETIMES USE
USE
Surgical resection
Radiotherapy
Surgical resection and post-operative
radiotherapy
Brachytherapy
Chemotherapy
NEVER
USE
4
6
2
33.33%
50%
16.67%
6
6
1
46.15%
46.15%
7.7%
7
7
0
50%
50 %
0%
1
5
4
10%
50%
40%
6
6
0
50%
50%
0%
12/16
13/16
14/16
10/16
12/16
Table 3: Modalities of treatment used in the management of patients with T4 cancer of the tongue or base
of the tongue as indicated by participants
TREATMENT MODALITY
NUMBER OF PARTICIPANTS
TOTAL NUMBER
OF PARTICIPANTS
ALWAYS USE
SOMETIMES USE
NEVER
1
4
1
16.7%
66.6%
16.7%
4
5
1
40%
50%
10%
6
7
0
46.15%
53.85%
0%
5
4
0
55.56%
44.44%
0%
1
7
3
9.09%
63.64%
27.26%
USE
Surgical resection
Radiotherapy
Surgical resection and post-operative
radiotherapy
Brachytherapy
Chemotherapy
20
6/16
10/16
13/16
9/16
11/16
HEALTH SA GESONDHEID Vol.11 No.3 - 2006
Different modalities of treatment may be used for patients with T4 as opposed to T3 cancers. Surgical resection (as single modality treatment) is used by five
participants (one always and four sometimes), while
one participant never uses surgical resection. Radiotherapy (as single modality treatment) is used by nine
participants (four always and five sometimes). One
participant never uses radiotherapy alone. The combination of surgical resection and post-operative radiotherapy is used by 13 participants (six always and seven
sometimes). Brachytherapy (as single modality treatment) is used by nine participants (five always and four
sometimes). Chemotherapy (as single modality treatment) is used by eight participants (one always and
seven sometimes); three participants never use chemotherapy. The majority of surgeons (13) prefer to use
combined modalities of treatment (surgery and postoperative radiotherapy). As single modality treatment,
radiotherapy is used by nine participants, brachytherapy
by nine participants, chemotherapy by eight participants and surgical resection by four participants. As in
the case with T3 cancer, the surgeon may opt for different approaches (modalities and combination of modalities) in different patients.
Current practices in speech and swallowing rehabilitation
Combination treatment (surgery and post-operative radiotherapy) is the preferred modality of treatment for
both T3 and T4 cancers of the tongue or base of the
tongue. The use of single modality treatment (surgery
alone and radiotherapy alone) declines with the shift
from T3 to T4 cancer. Chemotherapy is also used less
in the treatment of a T4 cancer than in the treatment of
a T3 cancer. Brachytherapy, however, is used more often in the treatment of a T4 cancer than a T3 cancer.
Speech-language pathologists were asked to indicate
swallowing and speech techniques used in the postoperative rehabilitation of patients who have undergone
total glossectomy. The results are shown in Tables 6
and 7. The majority of speech-language pathologists
always include dietary adjustments, compensatory
swallowing techniques and airway protection
mechanisms in their therapy management plan (See
Table 6). A variety of communication aspects, such as
speech intelligibility training, compensatory articulation
and alternative communication are included in the
communication rehabilitation of total glossectomy
patients (See Table 7). The majority of participants
included these three aspects of communication
intervention in their therapy. Additional information
gathered from the questionnaires were that slightly more
participants reported the need for alternative modes of
communication in total glosso-laryngectomy patients
(63.64% of participants) as opposed to patients with
laryngeal preservation (45.45% of participants).
Augmentative and alternative communication for this
population may include writing, devices such as
communication boards, or high technology devices such
as voice output systems. Speech-language pathologists
Surgeons were asked to indicate their estimation of
the years of survival of patients who have undergone
total glossectomy. The results are shown in Table 4.
Ten surgeons indicated that patients do not survive for
longer than three years after total glossectomy. Only
two surgeons are aware of patients that lived longer
than five years after total glossectomy.
With regard to referral of patients to speech-language
pathologists, most of the surgeons (13/16) always refer their patients. However, most of the surgeons refer
patients after surgery. Late referral prevents pre-operative counselling of the patient.
HEALTH SA GESONDHEID Vol.11 No.3 - 2006
Speech-language pathologists were asked to indicate
their annual caseload of patients who have undergone
total glossectomy with laryngeal preservation or total
glosso-laryngectomy. The results are summarised in
Table 5. Only 13 of the 55 participants reported
involvement in the treatment of total glossectomy
patients. The number of total glossectomy patients
treated annually by participants ranged between one
and eight patients per year. Three of the thirteen
participants did not treat patients on a yearly basis.
The majority of total glossectomy patients were treated
by therapists working in academic hospitals, followed
by therapists at universities and therapists in private
practice. Only two speech-language pathologists in
private practice have ever treated total glossectomy
patients. Four speech-language pathologists working
at universities said that they have treated total
glossectomy patients. The number of patients for these
participants ranged between two and ten (ten in 23
years).
21
Table 4: Estimation of years of survival of total glossectomy patients
NUMBER OF PARTICIPAN TS THAT
ESTIMATED SURVIVAL AFTER TOTAL
INDICATED ESTIMATED SURVIVAL
GLOSSECTOMY
2 (13.33%)
0-1 year
5 (33.33%)
1-2 years
3 (20%)
2-3 years
0 (0%)
3-4 years
3 (20%)
4-5 years
2 (13.33%)
5 years or more
Table 5: Caseload of speech-language pathologists with regard to patients who have undergone total
glossectomy or total glosso-laryngectomy
PARTICPANT
NUMBER OF TOTAL
NUMBER OF TOTAL GLOSSO-
NUMBER
GLOSSECTOMY PATIENTS
LARYNGECTOMY PATIENT S
TREATED ANNUALLY
TREATED ANNUALLY
1
10 (in 23 years)
5 (in 23 years)
2
?
?
3
2
2
4
1-2
1
5
2
6
6
6-8
2-3
7
2 (in 14 years)
0
8
1 (in 11 years)
0
9
?
0
10
1-2
1-2
11
5
2
12
3
1
13
1
1
Table 6: Feeding and swallowing techniques used in the post-operative rehabilitation of total glossectomy
patients
ASPECT OF FEEDING AND
FREQUENCY WITH WHICH ASPECTS ARE
TOTAL NUMBER
SWALLOWING INCLUDED IN
INCLUDED IN THERAPY
OF
PARTICIPANTS
THERAPY
Dietary adjustments
Compensatory swallowing techniques
Airway protection mechanisms
22
ALWAYS
SOMETIMES
NEVER
INCLUDE
INCLUDE
INCLUDE
13
0
0
100%
0
0%
12
1
0
85.71%
14.29%
0%
9
3
0
75%
25%
0%
13/13
13/13
12/13
HEALTH SA GESONDHEID Vol.11 No.3 - 2006
Table 7: Aspects of communication targeted in therapy by participants after total glossectomy with laryngeal preservation
ASPECT OF
FREQUENCY WITH WHICH ASPECTS ARE
TOTAL NUMBER
COMMUNICATION
INCLUDED IN THERAPY
OF PARTICIPANTS
INCLUDED IN THERAPY
Speech intelligibility
Compensatory articulation
Alternative communication
ALWAY S
SOMETIMES
NEVER
INCLUDE
INCLUDE
INCLUDE
7
1
1
77.78%
11.11%
11.11%
7
4
0
63.64%
36.36%
0%
5
6
0
45.45%
54.55%
0%
also reported that total glosso-laryngectomy patients
who did not receive voice prostheses use voiceless
speech (two participants), over-articulation (one
participant), gestures (five participants) and writing (eight
participants) for communication.
DISCUSSION
Caseload of surgeons and speech-language pathologists
Statistics regarding the caseload of advanced tongue
cancer patients in South Africa at different institutions
are not available. According to Hille and Shear
(2002:412) the incidence of head and neck cancer is
under-reported in South Africa. At the Multidisciplinary
Head and Neck Oncology Clinic of the Pretoria Academic Hospital 14% of all new patients with head and
neck malignancies evaluated at this clinic have malignancies of the tongue or tongue base (Pretoria Academic Multidisciplinary Head and Neck Oncology Clinic
Statistics, 2003, unpublished). A total number of 96
patients were treated for cancer of the tongue in 2003
(Pretoria Academic Multidisciplinary Head and Neck
Oncology Clinic Statistics, 2003, unpublished). These
statistics and the results of the current study do indicate that many cases of advanced cancer of the tongue
are reported and treated annually. However, only 16%
of surgeons responded and, only estimated and not
actual number of patients were provided. More exact
numbers should be determined in future research.
HEALTH SA GESONDHEID Vol.11 No.3 - 2006
9/13
11/13
11/13
The fact that the majority of patients with advanced
tongue cancer are treated in academic hospitals according to the current study may be an indication that
the majority of patients treated for advanced tongue
cancer are from poorer socio-economic backgrounds,
in need of state-funded hospital care. Risk factors for
tongue cancer include a poor diet (Macek, Reid &
Yellowitz, 2003:120), poor oral hygiene, poor dental care
(Becker, Naumann & Pfaltz, 1994:381), poverty, HIVinfection and pre-existing leukoplakia or erythroplakia
(Hille & Shear, 2002:411). These risk factors are frequently found in people from poor socio-economic environments in South Africa.
Only a small number of speech-language pathologists
treat total glossectomy patients annually. The question
arises as to why there are so few therapists working in
this field. Possible reasons are that these patients are
not always referred for treatment, or that speechlanguage pathologists are not confident in treating these
patients due to limited experience in the different
rehabilitation techniques available to treat these
patients. Thus they may not accept these patients as
part of their caseload. The majority of participants
(84.61%) felt that their undergraduate training was
insufficient to help them effectively treat total
glossectomy patients. Twelve of the thirteen participants
expressed the need to receive more information
regarding the speech and swallowing rehabilitation of
total glossectomy patients.
23
Total glossectomy versus total glossolaryngectomy as primary modality of
treatment for advanced tongue cancer
Different treatment modalities are available for the treatment of advanced tongue cancer. The surgeon has to
decide if surgery is a viable option, or refer the patient
for radiotherapy and/or chemotherapy. The surgical treatment of advanced tongue cancer remains a controversial issue. Total glossectomy has a severe psychological impact on the patient and some surgeons may be
hesitant to perform such a radical procedure. The majority of responding surgeons indicated that they prefer
to first do a total glossectomy with laryngeal preservation, and only perform total laryngectomy as a secondary procedure if it proves necessary. Only two surgeons
(working at academic hospitals) indicated that they always perform total glosso-laryngectomy in the absence
of cancer infiltration of the larynx. Many studies are
available debating the issue of preserving or resecting
the larynx (Harrison, 1983:632; Dudley, Carter & Russell,
1992:444; Davidson et al. 1993:160; Fox & Rau,
2001:161; Harrison et al. 2003:101). It appears that the
approach followed by most surgeons in South Africa,
in favour of laryngeal preservation, is consistent with
international trends (Harrison, 1983:638; Dudley et al.
1992:444; Davidson et al. 1993:160; Fox & Rau,
2001:166; Harrison et al. 2003:105).
The preservation of laryngeal voice must be weighed
against the possibility of aspiration and its consequences. If the larynx is preserved, aspiration may occur (Dudley et al. 1992:444). Chronic aspiration, in turn,
may lead to aspiration pneumonia (Logemann, 1998:5).
The possibility of aspiration and its influence on the
patient’s nutritional status and health needs to be carefully considered. The question of whether to preserve
the larynx is one with important implications given the
population we serve in South Africa. Many patients do
not have access to primary health care services and
live great distances from specialised services such as
speech and swallowing therapy (Fagan, Lentin,
Oyarzabal, Isaacs & Sellars, 2002:54). A patient not
able to access basic health care, may survive without
a voice, but would not be able to survive untreated aspiration pneumonia. It may be that the two surgeons who
indicated that they always perform total glosso-laryngectomy are not as radical as it appears. In the South
African context it may be a justified choice to resect
24
the larynx to protect the patient from further negative
consequences.
Communication and swallowing rehabilitation
Responding speech-language pathologists were aware
of the relevant procedures and techniques that need to
be employed to address the swallowing and communication problems following total glossectomy. Speechlanguage pathologists focus on the use of compensatory swallowing strategies to overcome the swallowing
problems associated with total glossectomy. They also
focus on compensatory articulation and speech intelligibility in the communication rehabilitation of total
glossectomy patients, although alternative communication is sometimes implemented in the case of total
glosso-laryngectomy patients. It would therefore seem
that therapists follow a holistic approach by implementing a variety of treatment strategies. Unfortunately this
study did not reveal whether speech-language pathologists in South Africa make use of the available Afrikaans, English and Tswana speech intelligibility tests,
or whether they only assess intelligibility subjectively.
Awareness of a scientific approach to speech intelligibility assessment and treatment needs to be raised.
Speech-language pathologists stated that augmentative and alternative communication aids are implemented
in the case of total glosso-laryngectomy patients.
Choosing an appropriate augmentative or alternative
communication aid becomes more problematic when
working with illiterate patients. As they cannot read or
write, these patients have to rely on gestures, voiceless speech or a picture-communication approach.
However, these techniques are very limited in allowing
the patients to express themselves. Furthermore, many
patients cannot afford highly technological devices used
in alternative communication, such as voice output systems (Harrison, 1983:638). This is particularly true for
patients in South Africa dependent on state-funded hospital care.
Survival rates
The poor long-term survival reported by surgeons is
consistent with international reports (Harrison,
1983:632; Davidson et al. 1993:163; Prince & Bailey,
1999:170). Harrison (1983:162) states that “despite
HEALTH SA GESONDHEID Vol.11 No.3 - 2006
enthusiastic surgery and adventurous radiotherapy”,
less than 50% of patients treated for advanced tongue
cancer survived longer than three years. The situation
has not changed much since. Five-year cure rates
following total glossectomy only reach 33%, with an
average of 20% (Davidson et al. 1993:163). This average
implies that only 20% of total glossectomy patients
survive for a period of five years. Ruhl et al. (1997:1321)
reported survival of 51% and 41% at three and five years
respectively for 54 total glossectomy patients.
DUDLEY, H; CARTER, D & RUSSELL, RCG (Eds) 1992: Operative
surgery; 4th edition. Oxford: Butterworth-Heinemann.
FAGAN, JJ; LENTIN, R; OYARZABAL, MF; ISAACS, S & SELLARS,
SL 2002: Tracheoesophageal speech in a developing world community. Archives of Otolaryngology Head and Neck Surgery, 128(1):50-57.
FOX, LE & RAU, MT 2001: Augmentative and alternative communication for adults following glossectomy and laryngectomy surgery. Augmentative and Alternative Communication,
17(3):161-166.
FURIA, CLB; CARRARA DE-ANGELIS, E; MARTINS, NMS;
The issue to be considered is whether total glossectomy
is worthwhile considering the poor survival rates. Only
the patient can make this choice. However, it is imperative that he or she receives all the available information and options before surgery. Poor survival rates
make it even more important to ensure the best quality
of life for patients who have undergone total
glossectomy. The quality of life of patients who have
undergone total glossectomy needs to be investigated
to determine the patient’s perception of post-operative
function and well-being.
BARROS, APB; CARNEIRO, B & KOWALSKI, LP 2000: Video fluoroscopic evaluation after glossectomy. Archives of Otolaryngology Head and Neck Surgery, 126(3):378-383.
FURIA, CLB; KOWALSKI, LP; LATORRE, MRDO; ANGELIS, CE;
MARTINS, NMS; BARROS, APB & RIBEIRO, KCB 2001: Speech
intelligibility after glossectomy and speech rehabilitation. Archives
of Otolaryngology Head and Neck Surgery, 127(7):877-883.
GÖTERT, GE & ARAS, E 1999: Mastication, deglutition and speech
considerations in prosthodontic rehabilitation of a total glossectomy
patient. Journal of Oral Rehabilitation, 26(1):75-79.
HARRISON, D 1983: The questionable value of total glossectomy.
Head and Neck Surgery, 6(2):632-638.
CONCLUSIONS
HARRISON, LB; LEE, HJ; PFISTER, DG; KRAUS, DH; WHITE, C;
RABEN, A; ZELEFSKY, MJ; STRONG, EW & SHAH, JP 1998: Long
Head and neck cancer is a specialised field, practised
by few surgeons and speech-language pathologists in
South Africa. Even though this study only determined
estimated numbers of patients, it is clear that many
patients are treated throughout South Africa. Medical
treatment and speech- and swallowing rehabilitation is
a challenge in the South African context, due to the
large number of illiterate patients and patients from
poorer socio-economic backgrounds. Many of these
patients present with advanced cancer of the head and
neck which is treated by radical surgery. Public awareness should be raised to encourage patients to seek
medical help early. Increased awareness may lead to
earlier diagnosis and less radical treatment of head and
neck cancer.
term results of primary radiotherapy with/without neck dissection for squamous cell cancer of the base of the tongue. Head
and Neck, 20(8):668-673.
HARRISON, LB; FERLITO, A; SHAKA, AR; BRADLEY, PJ; GENDEN,
EM & RINALDO, A 2003: Current philosophy on the management
of cancer of the base of the tongue. Oral Oncology, 39(2):101105.
HILLE, J & SHEAR, M 2002: Oral cancer: An underestimated killer.
South African Medical Journal, 92(6):410-412.
HIRANO, M; KUROIWA, Y; TANAKA, S; MATSUOKA, H; SATO, K
& YOSHIDA, T 1992: Dysphagia following various degrees of
surgical resection for oral cancer. Annals of Otology, Rhinology and Laryngology, 101(2 Pt 1):138-141.
KNUUTTILA, H; PUKANDER, J; MÄÄTTÄ, T; PAKARINEN, L &
VILKMAN, E 1999: Speech articulation after subtotal glossectomy
and reconstruction with a myocutaneous flap. Acta Otolaryn-
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